Disorders of the Pleura |

Use of Intrapleural Tissue Plasminogen Activator (TPA) and Deoxiribonuclease (DNAse) for Sympathetic Effusions FREE TO VIEW

Sebastian Ochoa, MD; Erik Folch, MD; Matt Del Guzzo, MD; Meghan Fashjian, NP; George Cheng, MD; Sidhu Ganghadaran, MD; Adnan Majid, MD
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Beth Israel Deaconess Medical Center, Boston, MA

Chest. 2015;148(4_MeetingAbstracts):438A. doi:10.1378/chest.2277207
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SESSION TITLE: Disorders of the Pleura Posters

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM

PURPOSE: Sympathetic pleural effusions are exudates arising from pleural irritation due to inflammation of adjacent structures. Complications include formation of loculations, which can preclude chest-tube drainage, often requiring surgical decortication. Previous studies have shown TPA-DNAse improves radiological resolution and reduces surgical referral in parapneumonic pleural effusions. This study aims to explore the safety and treatment efficacy of TPA-DNAse in sympathetic pleural effusions refractory to chest-tube drainage.

METHODS: We retrospectively reviewed data from 2010 to 2015 at a large tertiary center, and included patients with evidence of exudative effusion, no evidence of pulmonary infiltrates or infection in the pleural space, clear neighboring source of inflammation, and no response to chest-tube drainage. Baseline demographic characteristics, presenting symptoms, etiology of sympathetic effusion, and pleural fluid analysis were collected. Outcomes were total TPA-DNAse doses, treatment-related side effects, chest tube days, length of stay, radiologic improvement, surgical referral, and inpatient mortality. 3D reconstructions of pleural effusions from patients' low dose CT scans using OsiriX DICOM viewer were used to calculate effusion volume before and after TPA DNAse treatment.

RESULTS: Twelve patients (6 male, 6 female, mean age 50 years) with sympathetic pleural effusions who failed chest tube drainage were identified. Etiologies were intra-abdominal abscesses (n=9), anastomotic leaks (n=2), and ischemic bowel (n=1). Presenting symptoms were pleuritic chest pain (n=5), SOB (n=2), and fever (n=1). Pleural fluid analysis showed mean pH=7.4, total protein=4, LDH=520, cholesterol=78, glucose=94.5, median WBC=10,300 (N=60.9%, L=28.5%), and RBC=5,807. Pleural fluid gram stain and culture were negative in all cases. A median of of 2 doses of TPA-DNAse were used. There was 1 treatment-related adverse event (8%) (new bloody effusion after treatment and hematocrit drop). Mean length of stay was 19, and chest tube days 4.9. (83%, n=10). Mean radiologic improvement was 53% (412mL), and 17% (n=2) required surgery. There were no inpatient deaths.

CONCLUSIONS: Our study suggests that intrapleural TPA-DNAse is safe and effective in patients with sympathetic pleural effusions refractory to chest-tube drainage.

CLINICAL IMPLICATIONS: There are no currently approved medical treatments for chest-tube refractory sympathetic effusion. Our study is the first to explore the use of TPA DNAse in this patient population.

DISCLOSURE: The following authors have nothing to disclose: Sebastian Ochoa, Erik Folch, Matt Del Guzzo, Meghan Fashjian, George Cheng, Sidhu Ganghadaran, Adnan Majid

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